Cesarean Delivery

By
Julie S. Moldenhauer, MD, Associate Professor of Clinical Obstetrics and Gynecology in Surgery, The Garbose Family Special Delivery Unit; Attending Physician, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia; The University of Pennsylvania Perelman School of Medicine

Up to 30% of deliveries in the US are cesarean. The rate of cesarean delivery fluctuates. It has recently increased, partly because of concern about increased risk of uterine rupture in women attempting vaginal birth after cesarean delivery (VBAC).

Indications

Although morbidity and mortality rates of cesarean delivery are low, they are still several times higher than those of vaginal delivery; thus, cesarean delivery should be done only when it is safer for the woman or fetus than vaginal delivery.

Many women are interested in elective cesarean delivery on demand. The rationale includes avoiding damage to the pelvic floor (and subsequent incontinence) and serious intrapartum fetal complications. However, such use is controversial, has limited supporting data, and requires discussion between the woman and her physician; the discussion should include immediate risks and long-term reproductive planning (eg, how many children the woman intends to have).

Many cesarean deliveries are done in women with previous cesarean deliveries because for them, vaginal delivery increases risk of uterine rupture; however, risk of rupture with vaginal delivery is only about 1% overall (risk is higher for women who have had multiple cesarean deliveries or a vertical incision, particularly if it extends through the thickened, muscular portion of the uterus).

Vaginal birth is successful in about 60 to 80% of women who have had a single prior cesarean delivery and should be offered to those who have had a single prior cesarean delivery by low transverse uterine incision. Success of VBAC depends on the indication for the initial cesarean delivery. VBAC should be done in a facility where an obstetrician, anesthesiologist, and surgical team are immediately available, which makes VBAC impractical in some situations.

Technique

Classic: The incision is made vertically in the anterior wall of the uterus, ascending to the upper uterine segment or fundus. This incision typically results in more blood loss than a lower-segment incision and is usually done only when placenta previa is present, fetal position is transverse with the back down, the fetus is preterm, the lower uterine segment is poorly developed, or a fetal anomaly is present.

Lower segment: Lower-segment incisions are done most often. A low transverse incision is made in the thinned, elongated lower portion of the uterine body, and the bladder reflection is dissected off the uterus. A vertical lower-segment incision is used only for certain abnormal presentations and for excessively large fetuses. In such cases, a transverse incision is not used because it can extend laterally into the uterine arteries, sometimes causing excessive blood loss. Women who have had deliveries by a low transverse uterine incision are advised about the safety of a trial of labor in subsequent pregnancies.

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